This practice depends upon reimbursement from patients for the costs incurred in their care. All dental services must be paid for in cash/credit card at the time services are rendered.
Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. If your insurance does not pay within 45 days, our office reserves the right to request payment in full for services due from you. I understand that I am fully responsible to pay all fees that my insurance does not cover (realizing that all fees are Estimates and the final balance due could be different than the Estimated amount).
I understand that any fee estimate for my dental care can only be extended for a period of three months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if a balance is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all collection costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
I have read the above conditions of treatment and payment and agree to their content.